Radical cystectomy linked with poor survival in hemodialysis patients

A study published in Urologic Oncology found that radical cystectomy (RC) in patients undergoing dialysis is associated with significant morbidity and mortality; overall survival at five years was less than 15%. In addition, older patients and those with a history of diabetes or cerebrovascular disease (CVD) had an increased risk of mortality.

The investigators, led by Scott Johnson, MD, from the Department of Urology at the Medical College of Wisconsin in Milwaukee, retrospectively evaluated patients with end stage renal disease (ESRD) who underwent RC from 1984–2013 using the United States Renal Data System (USRDS). This database includes every patient who received hemodialysis (HD) in the US.

Patients who receive hemodialysis have an increased risk of advanced stage bladder cancer; specifically, their risk of bladder cancer is increased by more than 50%. Although the standard of care for localized muscle-invasive bladder cancer and high-risk nonmuscle-invasive bladder is RC, information about the outcomes in patients with ESRD on dialysis is limited.

Dialysis patients represent a unique population whose outcomes following RC may differ because they are more likely to have significant comorbidities, including cardiovascular disease. In addition, urinary diversion is the most significant source of perioperative morbidity from RC, and it may be omitted in patients who produce little or no urine.

Dr. Johnson and his colleagues wanted to characterize the perioperative outcomes and complications of patients with ESRD undergoing RC, as well as to determine long-term cancer-specific and all-cause mortality.

Patients with a diagnosis of bladder cancer who underwent RC were identified, and performance of urinary diversion and concurrent nephrectomy was determined. Demographics, medical history, cause of ESRD, and length of time on dialysis were also recorded. Perioperative outcome data were collected including length of stay, complications, readmissions, and mortality.

The investigators identified 985 patients in the USRDS with ESRD who underwent RC. Most patients were white males. The average age was 68.3 years, and the mean duration of HD was 3.2 years prior to RC. Cause of ESRD was varied, with no single cause accounting for more than 25% of the total.

Hypertension was the most common comorbidity; it was identified in 74% of patients. Most patients (68.5%) did not have a urinary diversion performed, and 40.6% of patients had a nephrectomy performed at the time of RC.

Overall, 43.1% of patients experienced at least one complication. The most common type of complication involved vascular access for dialysis (12%).

Mortality within 30 days of surgery was 9.3%. Cancer-specific mortality was 12.3%, 18.4%, and 19.7% at 1, 3, and 5 years, respectively. Overall mortality was 51.7%, 77.3%, and 87.9% at 1, 3, and 5 years, respectively. The most common cause of death was cardiovascular (42.5%).

The only significant association of cancer-specific mortality was active smoking status (hazard ratio [HR] = 1.70). Factors positively associated with all-cause mortality included age (HR = 1.02), diabetes (HR = 1.33), and CVD (HR = 1.48); a urinary diversion at the time of RC was associated with a protective effect (HR = 0.83).

The authors noted that most patients in this study did not undergo a concurrent nephrectomy and this had no identified impact on short- or long-term survival. They explain that although the performance of bilateral nephrectomy at the time of RC in ESRD patients is common, supportive data are limited.

Performing a urinary diversion at the time of RC is another issue of debate. The authors feel that when possible, avoiding urinary diversion would seem logical, as it is regarded as the major source of morbidity following RC. However, the investigators found that more than 30% of patients undergo urinary diversion of some type, and that it may offer an advantage in terms of overall survival. Furthermore, urinary diversion was not associated with increased risk of complications, although the reason for improved survival is not clear.

In this study, the risk of short-term mortality of ESRD patients following RC was substantial, and the overall risk of mortality following RC for ESRD patients was also significant. Less than half of patients survived one year and only 12% remained alive five years following RC. Mortality due to cancer was less substantial, approaching approximately 20% at five years.

The researchers feel that despite sobering perioperative and long-term outcomes, there remains a role for RC in carefully selected ESRD patients. They point out that younger patients without diabetes or CVD have the lowest risk of non-cancer mortality, efforts to avoid a urinary diversion to avoid morbidity of RC may be misguided, and performing a nephrectomy should be made on an individual basis.

The authors acknowledge that the study had some limitations. It was a retrospective analysis, and no control group was used. In addition, staging information and other surgical details were not available, and reporting of complications was not standardized.

“We have shown that perioperative and all-cause mortality are significant, consistent with prior small studies,” the authors concluded. “Young patients with minimal comorbidity have the lowest risk of overall mortality and may benefit most from RC. In our opinion, when performing RC in this population, urinary diversion should not necessarily be avoided and concurrent nephrectomy is not mandatory.”

To read more about this study, click here.